Anxiety-Children: January 2005

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Anxiety-Children
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5
5
Anxiety disorders
Thomas H. Ollendick1 and Laura D. Seligman2
1
Department of Psychology, Virginia Polytechnic Institute and State University, USA
2
Department of Psychology, University of Toledo, OH, USA
Introduction
The anxiety disorders constitute a broad spectrum of syndromes ranging from very
circumscribed anxiety to pervasive, sometimes ‘free-floating’ anxiety or worry. As
such, they are the most common group of psychiatric illnesses in children and
adolescents (as well as adults). With the most recent editions of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV; APA, 1994) and, similarly,
the International Statistical Classification of Diseases and Related Health Problems
(ICD-10; WHO, 1992), the symptoms of children, adolescents and adults can be
categorized by eight major but separate diagnostic syndromes associated with
anxiety: panic disorder with agoraphobia, panic disorder without agoraphobia,
agoraphobia without history of panic, specific phobia, social phobia, obsessive-
compulsive disorder, post-traumatic stress disorder and generalized anxiety
disorder.
Additionally, the DSM-IV and ICD-10 specify one anxiety disorder specific only
to childhood: separation anxiety disorder. Earlier versions of the DSM included
two additional anxiety diagnoses specific to childhood, namely avoidant disorder
and overanxious disorder. In the most recent revision, however, avoidant disor-
der and overanxious disorder have been subsumed under the categories of social
phobia and generalized anxiety disorder, respectively. Considerable evidence sug-
gests that avoidant disorder and overanxious disorder are not distinct syndromes
nor sufficiently different from their adult counterparts to merit separate diag-
nostic categories. For example, it has been shown that children and adolescents
with avoidant disorder are no different from those with social phobia on a vari-
ety of sociodemographic variables including race, socioeconomic status or age at
intake. Furthermore, neither rates of co-morbidity with affective disorders and
A Clinician’s Handbook of Child and Adolescent Psychiatry, ed. Christopher Gillberg,

Richard Harrington and Hans-Christoph Steinhausen. Published by Cambridge University Press.

C Cambridge University Press 2005.
144
145 Anxiety disorders
other anxiety disorders nor self-reported depression or fears were different for the
two groups of children and adolescents. Similarly, no appreciable differences have
been found between overanxious disorder and generalized anxiety disorder.
Although diagnostic systems such as the DSM and ICD describe anxiety as falling
into several distinct syndromes or categories, there is also a rich body of literature
examining anxiety at the symptom level. Rather than defining categorical distinc-
tions, this view embraces a dimensional approach, examining the number of anxiety
symptoms experienced by children and adolescents and the frequency or severity of
such symptoms. This tradition is best illustrated in the work of Achenbach and his
colleagues who have developed standardized measures such as the Child Behaviour
Checklist, Teacher Report Form and Youth Self-Report. A broad index of anxiety
is obtained from these measures.
As is evident, a wide range of topics is subsumed under the heading of anxiety
disorders in childhood. This chapter will be limited to that perspective which exam-
ines anxiety as syndromes or disorders and, more specifically, to the examination of
separation anxiety disorder, generalized anxiety/overanxious disorder, panic disor-
der, social phobia and specific (isolated) phobias. Obsessive-compulsive disorders
and post-traumatic stress disorders are considered separately in Chapters 6 and 8
of this volume.
Separation anxiety disorder (SAD)
Definition and classification

The main feature of SAD is an excessive and unrealistic fear of separation from a
major attachment figure that is unusual for the individual’s developmental level.
The DSM-IV and ICD-10 include a similar list of eight specific indicators of SAD
(see Table 5.1).
In general, both classification systems include symptoms related to:
r recurrent distress upon or in anticipation of separation
r worries about harm to the attachment figure or the child him or herself that
would result in separation
r difficulties in attending school or being alone or without the attachment figure
in other settings, problems sleeping alone
r nightmares about separation and
r physical symptoms either upon or in anticipation of separation.
Both require that the symptoms result in some degree of impairment; ICD-10 spec-
ifies that impairment is in the social domain whereas DSM-IV indicates that symp-
toms may result in impairment not only in social domains but also in academic,
family and other domains. DSM-IV and ICD-10 differ in terms of requirements for
146 T. H. Ollendick and L. D. Seligman
Table 5.1. Diagnostic criteria for separation anxiety disorder
DSM-IV ICD-10
A. Developmentally inappropriate and excessive The key diagnostic feature is a focused excessive
anxiety concerning separation from home or anxiety concerning separation from those
from those to whom the individual is attached, as individuals to whom the child is attached (usually
evidenced by three (or more) of the following: parents or other family members) that is not
1. recurrent excessive distress when separation merely part of a generalized anxiety about
from home or major attachment figures occurs multiple situations. The anxiety may take the
or is anticipated form of:
2. persistent and excessive worry about losing, (a) an unrealistic, preoccupying worry about
or about possible harm befalling, major possible harm befalling major attachment
attachment figures figures or a fear that they will leave and not
3. persistent and excessive worry that an return;
untoward event will lead to separation from a (b) an unrealistic, preoccupying worry that some
major attachment figure (e.g. getting lost or untoward event, such as the child being lost,
being kidnapped) kidnapped, admitted to hospital, or killed, will
4. persistent reluctance or refusal to go to school separate him or her from a major attachment
or elsewhere because of fear of separation figure;
5. persistently and excessively fearful or reluctant (c) persistent reluctance or refusal to go to school
to be alone or without major attachment because of fear about separation (rather than for
figures at home or without significant adults in other reasons such as fear about events at
other settings school);
6. persistent reluctance or refusal to go to sleep (d) persistent reluctance or refusal to go to sleep
without being near a major attachment figure without being near or next to a major
or to sleep away from home attachment figure;
7. repeated nightmares involving the theme of (e) persistent inappropriate fear of being alone, or
separation otherwise without the major attachment figure,
8. repeated complaints of physical symptoms at home during the day;
(such as headaches, stomachaches, nausea, or (f) repeated nightmares about separation;
vomiting) when separation from major (g) repeated occurrence of physical symptoms
attachment figures occurs or is anticipated (nausea, stomach ache, headache, vomiting,
etc.) on occasions that involve separation from a
major attachment figure, such as leaving home
to go to school;
(h) excessive, recurrent distress (as shown by
anxiety, crying, tantrums, misery, apathy, or
social withdrawal) in anticipation of, during, or
immediately following separation from a major
attachment figure.
Table 5.1. (cont.)
DSM-IV ICD-10
B. The duration of the disturbance is at least 4 weeks. Many situations that involve separation also involve
C. The onset is before age 18 years. other potential stressors or sources of anxiety. The
D. The disturbance causes clinically significant diagnosis rests on the demonstration that the
distress or impairment in social, academic common element giving rise to anxiety in the
(occupational), or other important areas of various situations is the circumstance of separation
functioning. from a major attachment figure. This arises most
E. The disturbance does not occur exclusively commonly, perhaps, in relation to school refusal (or
during the course of a Pervasive Developmental ‘phobia’). Often, this does represent separation
Disorder, Schizophrenia, or other Psychotic anxiety but sometimes (especially in adolescence) it
Disorder and, in adolescents and adults, is not does not. School refusal arising for the first time in
better accounted for by Panic Disorder With adolescence should not be coded here unless it is
Agoraphobia. primarily a function of separation anxiety and that
(a) Specify if: anxiety was first evident to an abnormal degree
(a) Early Onset: if onset occurs before age 6 years during the preschool years. Unless those criteria are
met, the syndrome should be coded in one of the
other categories in F93 or under F40–F48.
Excludes:
∗
mood [affective] disorders (F30–F39)
∗
neurotic disorders (F40–F48)
∗
phobic anxiety disorder of childhood (F93.1)
∗
social anxiety disorder of childhood (F93.2)
age of onset. While DSM-IV specifies an age of onset anytime prior to 18 years, the
ICD-10 indicates that separation concerns must be present during the preschool
years and SAD is only diagnosed during late childhood and adolescence when
symptoms are a continuation of concerns first manifested during early childhood.
DSM-IV is also more specific in that it requires symptoms to occur for a minimum
of 4 weeks; ICD-10 includes no specific criterion for minimum duration.
Finally, DSM-IV includes an early onset specifier. This applies in cases in which
symptom onset occurs prior to age six; this is not relevant for the ICD-10 diagnosis
since onset must be early. Little is known about the clinical implications of early
onset or whether youth with an early onset represent a distinct group.
Epidemiology
Prevalence and incidence rates

Most community surveys estimate the prevalence rate of SAD to be around
3.5–5 per cent. Young children mostly account for these cases as the rate in
adolescence decreases to less than 1 per cent. However, in prepubertal children

SAD tends to be the most commonly reported anxiety disorder in epidemiological
as well as referred clinical samples.
Sex ratios and ethnicity

SAD tends to be somewhat more common in girls than boys though in young chil-
dren the difference tends to be quite small and with older children and adolescents
discrepancies may be partially accounted for by the hesitancy of boys to report
separation fears.
The degree to which separation from attachment figures early in life is valued or
expected varies to a great degree across cultures. This may affect both the degree
to which separation concerns are interpreted as symptomatic and the amount of
distress and impairment engendered by the symptoms. Additionally, youth from
various ethnic backgrounds may present with somewhat different clinical pictures.
For example, some evidence suggests European-American youth are more likely
to present with school refusal as part of SAD while African-American youth may
more typically present with specific fears.
Implications for clinical practice

Prior to adolescence SAD is one of the most common anxiety disorders seen in
clinical practice, with roughly equal numbers of boys and girls seeking treatment.
Although the disorder may persist into adolescence and even adulthood, it is rela-
tively rare in post-pubertal children.
Clinical picture
Main features and symptoms

The main feature of SAD is excessive distress either before or during separation from
an attachment figure, usually the mother. Often this is manifested in tantrums when
separation is attempted. Somatic complaints in order to prevent separation or in
response to separation are also common.
School refusal is a particularly debilitating symptom and one that often serves
as the impetus for families to seek treatment. However, SAD is not the sole cause
of school refusal or school phobia and other causes such as social phobia and
oppositional behaviour must be considered.
Children with SAD may complain of sleep difficulties either because they are
unable to sleep alone or because they experience nightmares when they sleep.
Perceptual distortions, especially at night or surrounding bedtime may also be
reported. For example, these children may interpret noises or shadows as burglars. In
addition, the refusal to separate may interfere with academic performance and some
children with SAD may have missed significant amounts of schooling before coming
for treatment. Similarly, because of the reluctance to engage in social activities
that result in separation, especially overnight activities, youth with SAD may have
significantly limited opportunities for socialization and many report at least some
degree of social problems.
The added parenting responsibilities that often come along with having a child
with SAD may cause conflict and distress among family members and in some cases
the parent (or other attachment figure) may also report anxiety around separating
from the child.
Differential diagnosis and co-morbidity

SAD is often co-morbid with other anxiety disorders and depression. Although it
is thought that SAD may develop into panic disorder (PD) later in life, concurrent
comorbidity is rare in that SAD is evident mostly in young children and panic
disorder rarely manifests itself until adolescence. Children with SAD may, however,
experience panic attacks upon, or in anticipation of, separation. This condition can
be distinguished from PD in that the child is fearful of separation or an event, such
as kidnapping, that would result in separation and not the panic attack itself.
SAD may also be confused with generalized anxiety disorder (GAD), given that
children may express numerous fears; however, in SAD the fears revolve around the
theme of separation or a threat that would result in separation whereas in GAD there
may be no unifying theme or numerous, broad or overarching themes. Children
with GAD may also dwell on worries about past events while this would be less
typical of children with SAD.
When school refusal is a primary symptom, SAD must be differentiated from
social phobia, oppositional defiant disorder, or even a specific phobia.
r It must be determined whether the child is motivated to avoid characteristics
of the school environment itself, in which case a diagnosis of social or specific
phobia may be more appropriate.
r If the child refuses to go to school because this enables him or her to engage in
activities that are more reinforcing than schoolwork or if the refusal is used as a
form of retaliation, a diagnosis of Oppositional Defiant Disorder (ODD) should
be considered. It may be helpful to keep in mind that SAD may be seen more
often in younger children while more serious manifestations of ODD are more
likely in older children.
r If the child would experience little or no discomfort at school if the primary
attachment figure was there or when the child’s concerns centre around harm
befalling the attachment figure or the child him or herself a diagnosis of SAD is
most likely.
Assessment
Most diagnostic interviews designed for use with young children contain sections
for the assessment of SAD and can be used in conjunction with a clinical inter-
view. The Anxiety Disorders Interview Schedule for Children (ADIS-IV/C+P) was
designed specifically to assess for anxiety disorders and, as such, it may be the most
appropriate when anxiety is the primary concern. Other useful diagnostic inter-
views include the NIMH Diagnostic Interview Schedule for Children (DISC) and
the Diagnostic Interview for Children and Adolescents–Revised (DICA-R).
Many questionnaires exist to assess anxiety in youth and some of the more
recent ones have items that map directly onto the SAD diagnostic criteria. Rec-
ommended self-report instruments include the Multidimensional Anxiety Scale
for Children (MASC), the Screen for Child Anxiety Related Emotional Disorders
(SCARED), the Spence Children’s Anxiety Scale (SCAS) and the Fear Survey Sched-
ule for Children – Revised (FSSC-R, see Appendix 5.1). A list of recommended
interviews and questionnaires can be found in Table 5.2. Although these instru-
ments are not specific to SAD in that they assess for other anxiety disorders or the
physiological, cognitive and subjective components of anxiety in general, they can
be helpful in obtaining information about SAD and differentiating it from related
disorders.
In order to assess for co-morbidity and to assist in differential diagnosis, a
thorough assessment for depression should be conducted. The Children’s Depres-
sion Inventory (CDI) might be considered under such circumstances. When school
refusal is present, the School Refusal Assessment Scale (SRAS) can be a useful aid
for differential diagnosis.
Generalized anxiety disorder

Both the DSM-IV and the ICD-10 identify the main features of GAD as:
r excessive free-floating worry
r somatic symptoms associated with the worry or as a result of the worry (e.g.
tension headaches).
The complete diagnostic criteria for GAD according to both classification systems
are presented in Table 5.3. All of the symptoms of GAD specified in ICD-10 are
included in the DSM-IV diagnostic criteria, although they are separated and the
conceptual organization is somewhat different. In addition, DSM-IV goes further
in that it specifies that the worry must be difficult to control. The DSM-IV is also
more specific in terms of the duration of symptoms required (i.e. 6 months) and
the number of somatic symptoms that must be present (i.e. three for adults and
Table 5.2. Representative assessment options: description and psychometric properties
Instrument Description Subscales/procedural comments Psychometric properties
Anxiety Disorders Interview Structured diagnostic clinical Screens for all childhood internalizing – Inter-rater reliability 0.98 ADIS-C, 0.93
Schedule – Child / Parent interview, child and parent and externalizing disorders of DSM-IV ADIS-P;
(ADIS-C/P). Source: Silverman, versions. but especially useful for the anxiety and – Retest reliability 0.76 ADIS-C, 0.67 ADIS-P;
W. K. & Albano, A. M. (1996). phobic disorders. – Sensitivity to treatment effects for childhood
Anxiety Disorders Interview anxiety and phobias.
Schedule for DSM-IV, Child and
Parent Versions. San Antonio, TX:
Psychological Corporation.
Behavioural avoidance tests (BAT; Although heterogeneity for BAT Differing opinions regarding the number – BAT performance seems to be reliable for any
in vivo, exposure-based assessment procedures exists in the literature, of steps, as well as differing steps for one type of BAT for any one given child;
of approach/avoidance of a phobic typically a child is asked to enter a different stimuli. For example, our – However, the heterogeneity of procedures
stimulus) room containing the relevant phobia project currently uses 10 steps for makes large comparisons difficult across
Source: Ollendick, T. H. & Cerny, phobic stimulus. The child’s dog phobia and 13 steps for snake studies;
J. A. (1981). Clinical Behavior approach toward the stimulus is phobia. – Issues of test-retest reliability and
Therapy with Children. New York: recorded and a percentage of steps standardization of procedures are currently
Plenum Press. or stages completed out of the total being addressed by our phobia project.
number of steps is calculated.
Child Anxiety Sensitivity Index Self-report measure consisting of Consists of a total score and three – Excellent to satisfactory retest reliability (0.76
(CASI). Source: Silverman, W. K., 18 items, Likert scale (3-point: subscale scores: physical concerns, for clinical sample and 0.79 for non-clinical
Fleisig, W., Rabian, B. & Peterson, none, some a lot). Assesses fear of mental incapacitation concerns and sample at 2-week interval);
R. (1991). Childhood Anxiety anxiety symptoms or ‘fear of fear’. social concerns. – Internal consistency 0.87;
Sensitivity Index (CASI). Journal of Useful for ages 7–16. – Anxious children have significantly higher total
Clinical Child Psychology, 20, and subscale scores than non-clinical matched
162–8. App. B controls.
(cont.)
Table 5.2. (cont.)
Child Behaviour Checklist (CBCL); Measure typically filled out by a Separates internalizing and externalizing – Satisfactory to excellent retest reliability
Source: Achenbach, T. M. (1991). child’s parent or caretaker. Inquires difficulties into various problem scales (approx 0.89 at 1 week, 0.75 at 1 year, 0.71 at
Integrative guide for the 1991 generically into a child’s skills, which can be useful: withdrawn, somatic 2 years;
CBCL/4–18, YSR, and TRF profiles. behaviours, interactions, and complaints, anxious/depressed, social – Inter-rater agreement approx 0.65 to 0.75 for
Burlington: University of Vermont. hobbies. Age range 4 to 18 years. problems, thought problems, attention parents;
problems, delinquent behaviour and – Scaled scores can be interpreted such that there
aggression is an 89.1% correct classification rate.
Direct Observation of Anxiety A child’s anxious behaviours (e.g. Various protocols exist for the – Diverse methodologies and coding systems
(DOA). Source: Ollendick, T. H. & shaking, sweating, clinging, observation of many different types of exist.
Cerny, J. A. (1981). Clinical trembling, crying) are typically anxiety. These differing methodologies – Reliabilities are reported to range from low to
Behavior Therapy with Children. coded by an observer based upon a also incorporate differing numbers of very high depending on the coding protocol.
New York: Plenum Press. predetermined observation behaviours to be recorded.
system.
Fear Survey Schedule for Self-report, measure consisting of Consists of a total score and five – Excellent to satisfactory retest reliability
Children–Revised (FSSC-R). Source: 80 specific phobia items, Likert subscales: fear of failure, fear of the (approx. 0.82 at 1 week and 0.55 at 3 months),
Ollendick, T. H. (1983). Reliability scale (3-point: none, some, a lot). unknown, fear of injury and small Alpha = 0.95;
and validity of the Revised Fear Useful for ages 7–16. animals, fear of danger and death, and – School phobic children have significantly
Survey Schedule for Children medical fears. higher total scores than matched controls, as do
(FSSC-R). Behaviour Research and children with specific phobias;
Therapy, 21 685–92. App. A. – Discriminates significantly between different
types of specific phobia when completed by
parent or child.
Multidimensional Anxiety Scale for Measures wide range of anxiety Four factors with subfactors including – – Internal reliability of total score is 0.90;
Children (MASC). Source: March, symptoms, Likert scale (4-point) physical symptoms (tense/somatic), – Satisfactory to excellent retest reliability (0.79 at
J., Parker, J., Sullivan, K., Stallings, self-report, 39-items, age range 8 to harm avoidance (anxious 3 weeks, 0.93 at 3 months);
P. & Conners, C. K. (1997). The 18 years. coping/perfectionism), social anxiety – Good convergent validity with RCMAS (0.63);
MASC: Factor structure, reliability, (humiliation/performance) and – Excellent discriminative validity between
and validity. Journal of the separation anxiety. anxious and normal controls with 87% correct
American Academy of Child and classification.
Adolescent Psychiatry, 36, 554–65.
Revised Children’s Manifest Anxiety Self-report, measure consisting of Consists of a total anxiety score and four – Satisfactory retest reliability (approx. 0.68 at
Scale (RCMAS). Source: Reynolds, 37 items related to anxiety, age subscale scores: physiological anxiety, 9 months);
C. R. & Richmond, B. O. (1985). range 6 to 19 years, response is ‘yes’ worry/oversensitivity, concerns/ – Discriminates significantly between state and
Revised Children’s Manifest Anxiety or ‘no’. concentration, social and lie/social trait anxiety when compared to the STAIC
Scale manual. Los Angeles: Western desirability. (RCMAS scores associated with ‘chronic
Psychological Services. manifest or generalized anxiety’.
Screen for Child Anxiety Related Self-report measure consisting of Consists of a total scale score and seven – Internal reliability of total score is 0.94;
Emotional Disorders – Revised 66 items related to DSM-IV anxiety subscale scores: separation anxiety – Internal reliability of specific phobia scale is
(SCARED-R). Source: Muris, P., disorders, age range 8 to 18 years, disorder, generalized anxiety disorder, 0.58- 0.71;
Merckelbach, H., Schmidt, H. & response is on a 3-point Likert panic disorder, social phobia, – Good convergent validity with FSSC-R (total
Mayer, B. (1999). The revised scale. obsessive-compulsive disorder, traumatic Scale correlates 0.64);
version of the SCARED-R: Factor stress disorder and specific phobias. – Discriminates significantly between anxious
structure in normal children. and disruptive disorders.
Personality and Individual
Differences, 26, 99–112.
Spence Child Anxiety Scale (SCAS). Self-report measure consisting of Consists of a total scale score and six – Internal reliability of total score of 0.93;
Source: Spence, S. H. (1997). 38 items related to DSM-IV anxiety subscale scores: separation anxiety, – Internal reliability of subscales all above 0.80;
Structure of anxiety symptoms disorders, age range 8 to 16 years, generalized anxiety, panic, social phobia, – Good convergent validity with RCMAS and
among children: a confirmatory response is on a 4-point Likert obsessive-compulsive and fears/phobias. internalizing score of CBCL but not
factor-analytic study. Journal of scale ranging from never to always. Externalizing Score;
Abnormal Psychology, 106, 280–97. – Discriminates significantly between anxious
and disruptive behaviour disorders.
(cont.)
Table 5.2. (cont.)
Spider Phobia Questionnaire Source: Self-report measure consisting of Scores on all items are summed to create – Satisfactory test – retest reliability (approx 0.61
Kindt, M., Brosschot, J. F. & Muris, 29 spider phobia related items, a total score that suggests the degree of at 6–7 weeks);
P. (1996). Spider phobia response is ‘true’ or ‘not true’. spider fear. – Discriminates significantly between spider
questionnaire for children phobic and non-phobic girls.
(SPQ-C): a psychometric study
and normative data. Behaviour
Research and Therapy, 34, 277–82.
Teacher Report Form (TRF). Source: Measure typically filled out by a Separates internalizing and externalizing – Satisfactory to excellent retest reliability
Achenbach, T. M. (1991). child’s teacher. Inquires generically difficulties into various problem scales (approx. 0.9 at 2 weeks, 0.75 at 2 months, 0.66 at
Integrative Guide for the 1991 into a child’s skills, interactions, which can be useful: withdrawn, somatic 4 months);
CBCL/4–18, YSR, and TRF Profiles. and hobbies, as well as maladaptive complaints, anxious/depressed, social – Inter-rater agreement approx 0.54 for teachers
Burlington: University of Vermont. behaviours. problems, thought problems, attention seeing students in different settings;
problems, delinquent behaviour and – Scaled scores can be interpreted such that there
aggressive behaviour. is a 79.3% correct classification rate.
Youth Self-Report (YSR). Source: Measure typically filled out by the Separates internalizing and externalizing – Satisfactory retest reliability (approx. 0.72 at
Achenbach, T. M. (1991). child. Inquires generically into a difficulties into various problem scales 1 week, 0.49 at 7 months);
Integrative Guide for the 1991 child’s skills, interactions, and which can be useful: withdrawn, somatic – Scaled scores can be interpreted such that there
CBCL/4–18, YSR, and TRF Profiles. hobbies, as well as problematic complaints, anxious/depressed, social is a 71.9% correct classification rate.
Burlington: University of Vermont. behaviours. problems, thought problems, attention
problems, delinquent behaviour and
aggressive behaviour.
Table 5.3. Diagnostic criteria for generalized anxiety disorder
DSM-IV ICD-10
A. Excessive anxiety and worry (apprehensive The sufferer must have primary symptoms of
expectation), occurring more days than not for at anxiety most days for at least several weeks at a
least 6 months, about a number of events or time, and usually for several months. These
activities (such as work or school performance). symptoms should usually involve elements of:
B. The person finds it difficult to control the worry. (a) apprehension (worries about future
C. The anxiety and worry are associated with three (or misfortunes, feeling ‘on edge’, difficulty in
more) of the following six symptoms (with at least concentrating, etc.);
some symptoms present for more days than not for (b) motor tension (restless fidgeting, tension
the past 6 months). Note: Only one item is required headaches, trembling, inability to relax); and
in children. (c) autonomic overactivity (lightheadedness,
1. restlessness or feeling keyed up or on edge sweating, tachycardia or tachypnoea, epigastric
2. being easily fatigued discomfort, dizziness, dry mouth, etc.).
3. difficulty concentrating or mind going blank In children, frequent need for reassurance and
4. irritability recurrent somatic complaints may be prominent.
5. muscle tension The transient appearance (for a few days at a time)
6. sleep disturbance (difficulty falling or staying of other symptoms, particularly depression, does
asleep, or restless unsatisfying sleep) not rule out generalized anxiety disorder as a main
D. The focus of the anxiety and worry is not confined diagnosis, but the sufferer must not meet the full
to features of an Axis I disorder, e.g. the anxiety or criteria for depressive episode, phobic anxiety
worry is not about having a panic attack (as in panic disorder, panic disorder, or obsessive-compulsive
disorder), being embarrassed in public (as in social disorder.
phobia), being contaminated (as in
Includes:
obsessive-compulsive disorder), being away from ∗
anxiety neurosis
home or close relatives (as in separation anxiety ∗
anxiety reaction
disorder), gaining weight (as in anorexia nervosa), ∗
anxiety state
having multiple physical complaints (as in
somatization disorder), or having a serious illness
(as in hypochondriasis), and the anxiety and worry
do not occur exclusively during post-traumatic
stress disorder.
E. The anxiety, worry, or physical symptoms cause Excludes:
clinically significant distress or impairment in social, ∗ neurasthenia
occupational, or other important areas of
functioning.
F. The disturbance is not due to the direct physiological
effects of a substance (e.g. a drug of abuse, a
medication) or a general medical condition (e.g.
hyperthyroidism) and does not occur exclusively
during a mood disorder, a psychotic disorder, or a
pervasive developmental disorder.
adolescents, 1 for children). DSM-IV also requires clinically significant impairment

as a result of the symptoms.
A significant difference between the two classification systems is that the ICD-10
does not allow for the dual diagnosis of GAD with Depression, Panic Disorder,
Obsessive-Compulsive disorder, or a phobic disorder. DSM-IV, on the other hand,
specifies that the worry must not be limited to a theme that would be better
accounted for by another disorder; however, if this criterion is met, it does allow
for comorbid diagnoses.
GAD now subsumes the diagnosis of Overanxious Disorder of childhood, present
in DSM-III-R and ICD-9. The primary difference between GAD and Overanxious
Disorder is in the greater emphasis on somatic symptoms in the GAD diagnosis.
However, DSM-IV does specify modifications to the number of somatic symptoms
that must be present in children. In addition, the worry described by GAD is a
future focused worry or anxious apprehension whereas the criteria for Overanxious
Disorder indicated that children may worry about their performance and behaviour
during past events as well.
Epidemiology

If it is assumed that children who had previously met diagnosis for Overanxious
Disorder would meet the current GAD diagnostic criteria, prevalence rates for GAD
in community samples is around 6 per cent. Some studies, however, suggest a much
lower rate, even below 1 per cent.

The disorder appears to be somewhat more common in girls than boys and more
frequently affects older children and adolescents.
Although some form of GAD seems to be present across many cultures, the ways
in which anxiety and apprehension are expressed may vary. For example, although
some children may openly express and verbalize anxious concerns, for others this
may be manifested as perfectionism or numerous somatic complaints.

GAD is not uncommon in help-seeking samples but may masquerade as a physical
complaint for some time before the emotional component of the disorder is recog-
nized. Frequently, GAD co-occurs with both SAD and the depressive disorders. As
a result, differential diagnosis is critical.
Clinical picture

Youth presenting with GAD may first come in with physical complaints and may
have sought medical treatment numerous times before being recognized. These
children may be perfectionist and, although some children and adolescents with
GAD express age-consistent worries such as concerns about school and athletic
performance, others will express concerns that appear to be beyond their years,
such as the state of world affairs and the possibility of war or concerns about family
economics or parental job security. Often concerns focus on health issues both
for the child and other family members. Children may seek excessive reassurance
or comfort from family members, or in some cases, the child, may have limited
activities in order to avoid information that has the potential to lead to additional
worries. For example, some parents of GAD children will not allow the child to
watch television in order to avoid any news stories that could cause or exacerbate
the child’s concerns.
Anxiety disorders and depression are not unusual in family members of children
with GAD so the clinical picture may be complicated by impairment or limited
functioning in the child’s care providers.

Differential diagnosis and co-morbidity will vary with the diagnostic system used.
Without restrictions, GAD is often co-morbid with depression and other anxiety
disorders, particularly SAD.
Because of the somatic complaints present in GAD and the physical disorders
that may cause tension or mimic anxiety, it is important that a thorough physi-
cal examination is conducted to differentiate GAD from physical disorders such
as hyperthyroidism. Moreover, if somatic complaints coupled with worries about
health and disease limited to the child him or herself are the only concern, a somato-
form disorder should be considered.
Additionally, if numerous worries are present but revolve around a unified theme
such as social embarrassment or separation, the more specific anxiety disorder
diagnosis is appropriate. GAD must also be distinguished from eating disorders
(see Chapter 10) if the worries are solely related to weight or appearance; concerns
about appearance are often present in youth with GAD but are part of a larger
picture of more diffuse worries. In addition, given the nature of obsessional worry
in GAD it can be difficult to distinguish from OCD. In GAD the worry tends to be
around realistic or everyday concerns although the degree of worry is excessive; in
OCD, the worry tends to be of a less realistic nature and is typically ego-dystonic.
For young children the latter distinction, however, may either not be true or can be
difficult to assess.
Assessment
Although no specific instruments to assess GAD in youth are in widespread use, the
diagnostic interviews and questionnaires listed in Table 5.2 provide information
for the diagnosis of GAD and associated symptomatology. In addition, the Revised
Children’s Manifest Anxiety Scale (RCMAS) is frequently used to measure gener-
alized or ‘manifest’ anxiety, even though it is becoming somewhat outdated at this
time.
Panic disorder

The primary diagnostic features of PD according to both the DSM-IV and the
ICD-10 are:
r recurrent, intense but time-limited periods of fear
r the attacks must be unexpected or at least initially not associated with a specific
situation
r the attacks involve autonomic and/or cognitive symptoms such as fears that one
will go crazy or die.
The DSM-IV and ICD-10 criteria for PD are listed in Table 5.4. In addition, the
DSM-IV criteria for a panic attack and for agoraphobia are listed in Tables 5.5 and
5.6, respectively. Both the DSM-IV and the ICD-10 require that multiple panic
attacks occur within a period of 1 month to meet criteria for PD. In general, as
with the other anxiety disorders, the diagnostic criteria included in DSM-IV are
somewhat more specific. For instance, DSM-IV requires a minimum of four attacks
within a 1-month period and a minimum of 4 of 13 specified autonomic or cognitive
symptoms to constitute a full-blown panic attack. DSM-IV also recognizes that
the attacks, although initially unpredictable, may become associated with certain
situations or cues over time.
Despite the similarities in the two classification systems, two important concep-
tual differences exist. First, the DSM-IV requires at least a 1-month period in which
there is a change in behaviour pursuant to the attacks or that the individual develops
a fear of additional attacks or their implications. Thus, in the DSM system, the core
of the disorder is what is commonly termed ‘the fear of fear’, whereas in the ICD
system the presence of panic attacks – not the fear of fear – constitutes the disor-
der. This is an important distinction in that panic attacks can and do occur with
other disorders and, while many individuals experience panic attacks, those who
Table 5.4. Diagnostic criteria for panic disorder
DSM-IV ICD-10
Panic Disorder With Agoraphobia In this classification, a panic attack that occurs in an
A. Both (1) and (2) established phobic situation is regarded as an expres-
(1) recurrent unexpected panic attacks sion of the severity of the phobia, which should be
(2) at least one of the attacks has been followed given diagnostic precedence. Panic disorder should
by 1 month (or more) of one (or more) of the be the main diagnosis only in the absence of any of
following: the phobias in F40.
(a) persistent concern about having For a definite diagnosis, several severe attacks of auto-
additional attacks nomic anxiety should have occurred within a period
(b) worry about the implicaton of the attack of about 1 month:
or its consequences (e.g. losing control, (a) in circumstances where there is no objective
having a heart attack, ‘going crazy’) danger;
(c) a significant change in behaviour related (b) without being confined to known or predictable
to the attacks situations; and
B. The presence of agoraphobia (c) with comparative freedom from anxiety
C. The panic attacks are not due to the direct symptoms between attacks (although
physiological effects of a substance (e.g. a drug of anticipatory anxiety is common).
abuse, a medication) or a general medical
Includes:
condition (e.g. hyperthyroidism). ∗
panic attack
D. The panic attacks are not better accounted for by ∗
panic state
another mental disorder, such as social phobia
(e.g. occurring on exposure to feared social
situations), specific phobia (e.g. on exposure to a
specific phobic situation), obsessive-compulsive
disorder (e.g. on exposure to dirt in someone
with an obsession about contamination),
post-traumatic stress disorder (e.g. in response to
stimuli associated with a severe stressor), or
separation anxiety disorder (e.g. in response to
being away from home or close relatives).
Note: The criteria for panic disorder without agoraphobia are identical with the exception of criteria B which
states ‘The Absence of Agoraphobia’.
interpret them as dangerous or become preoccupied with a possible reoccurrence

appear to constitute the PD group that experiences considerably more associated
impairment.
The second difference is that in the DSM-IV agoraphobia is always consid-
ered in the diagnosis of PD. Three possible diagnoses are available, PD without
Agoraphobia, PD with agoraphobia, and agoraphobia without history of panic,
Table 5.5. DSM-IV definition of a panic attack
A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms
developed abruptly and reached a peak within 10 minutes:
1. palpitations, pounding heart, or accelerated heart rate
2. sweating
3. trembling or shaking
4. sensations of shortness of breath or smothering
5. feeling of choking
6. chest pain or discomfort
7. nausea or abdominal distress
8. feeling dizzy, unsteady, lightheaded, or faint
9. derealization (feelings of unreality) or depersonalization (being detached from oneself)
10. fear of losing control or going crazy
11. fear of dying
12. paresthesias (numbness or tingling sensations)
13. chills or hot flushes
Table 5.6. DSM-IV definition of agoraphobia
A. Anxiety about being in places or situations from which escape might be difficult (or
embarrassing) or in which help may not be available in the event of having an unexpected
or situationally predisposed panic attack or panic-like symptoms. Agoraphobic fears
typically involve characteristic clusters of situations that include being outside the home
alone; being in a crowd or standing in a line; being on a bridge; and traveling in a bus, train,
or automobile.
Note: Consider the diagnosis of specific phobia if the avoidance is limited to one or only a
few specific situations, or social phobia if the avoidance is limited to social situations.
B. The situations are avoided (e.g. travel is restricted) or else are endured with marked distress
or with anxiety about having a panic attack or panic-like symptoms, or require the presence
of a companion.
C. The anxiety or phobic avoidance is not better accounted for by another mental disorder,
such as social phobia (e.g. avoidance limited to social situations because of fear of
embarrassment), specific phobia (e.g. avoidance limited to a single situation like elevators),
obsessive-compulsive disorder (e.g. avoidance of dirt in someone with an obsession about
contamination), post-traumatic stress disorder (e.g. avoidance of stimuli associated with a
severe stressor), or separation anxiety disorder (e.g. avoidance of leaving home or relatives).
although this latter diagnosis is less commonly applied, especially in children. No

such link is made in the ICD-10. This is because the DSM-IV considers agoraphobia
to be avoidance of situations or excessive anxiety about being in situations in which
a panic attack might take place or in which it would be difficult to escape should an
attack occur. In contrast, ICD-10 considers agoraphobia to be the fear of open or
crowded places or a fear of situations in which escape might be difficult. Although

ICD-10 provides diagnostic codes to indicate the presence or absence of PD when
agoraphobia is the main diagnosis, no explicit conceptual link is made.
Epidemiology

PD is rare in prepubertal children and some believe that the condition does not
exist prior to puberty. Others, however, have shown that panic attacks certainly
occur prior to pubescence, and that PD itself can and does occur (although infre-
quently). Typical onset is either in adolescence or young adulthood. In adolescence,
PD is less common than many of the other anxiety disorders, occurring in about
1 per cent of youth.

PD is seen more commonly in girls than boys, as is the associated agoraphobic
avoidance. Currently, no data are available about ethnic or cultural differences.

Although PD is not seen commonly in paediatric community samples, the degree
of impairment engendered by the disorder, especially when it is accompanied by
agoraphobic avoidance, can often cause those who are affected to seek treatment. It
is critical that it be differentiated from medical conditions such as hyperventilation
syndrome and asthma in such instances.
Clinical picture

Youth seeking treatment may present because of intense fear about the meaning
of the attacks or because of the interference in functioning engendered by the
agoraphobic avoidance. Many times, families will have sought medical treatment
or may believe that the attacks have a serious underlying physiological cause that
has not been discovered.
By the time treatment is sought, the child may have missed significant amounts
of school as a result of the panic attacks. Agoraphobic avoidance of places such as
shopping malls, sporting events, and theatres and restaurants may result in severely
restricted social opportunities and development.
Often separation concerns may accompany the PD or may have preceded it.
Significant anxiety between attacks is not unusual and depressive symptoms and
hopelessness may accompany the panic attacks particularly if the family has been
unsuccessful in obtaining adequate treatment, resulting in a prolonged period of
symptoms.

PD is often accompanied by other anxiety disorders or symptoms, especially early
onset SAD. However, it should be noted that some studies have found a high rate of
co-morbid separation anxiety in youth with PD whereas others have not. Affective
disturbances are common.
Panic attacks may occur in the context of other anxiety disorders such as social or
specific phobias. In this case the attacks are situationally cued from the onset and the
diagnosis of PD would not be appropriate. Additionally, PD can be differentiated
from other anxiety disorders, such as GAD, in that those with PD experience discrete
periods of intense anxiety. That is, while there is some debate on this issue, panic
attacks are thought to last for a period of minutes, not days or hours. Worry about
the reoccurrence of the attacks, on the other hand, continues long after the attack has
subsided. In disorders such as GAD, the patient typically reports no discrete periods
of worry but rather constant worry perhaps with periods of varying intensity.
Given the nature of the physical symptoms of panic attacks, PD must be differen-
tiated from potentially serious medical conditions such as asthma, hyperventilation
disorder, irregular heart rhythms, mild myocardial infarctions and thyroid dysfunc-
tion. PD can, however, accompany or be exacerbated by a medical condition.
Assessment
In addition to the general measures listed in Table 5.2 (e.g. MASC, SCARED, SCAS,
FSSC-R), the Children’s Anxiety Sensitivity Index (CASI, see Appendix 5.2) has
been found to be useful. This instrument measures sensitivity to the actual cues
of anxiety (i.e. the ‘fear of fear’). In addition, individually tailored self-monitoring
forms can be useful in diagnosis and treatment planning as well as monitoring
treatment progress. Ideally, the panic attack symptoms, as well as the situations in
which they occur and their severity, should be noted. Frequency of attacks as well
as frequency of agoraphobic avoidance (or approach towards previously avoided
situations) should also be recorded.
Due to the physical nature of the complaints involved in PD, it is important that
a thorough physical examination with accompanying laboratory tests be conducted
in order to rule out a medical condition that could account for the symptoms (e.g.
hyperventilation disorder, asthma).
Social phobia (social anxiety disorder)

The main diagnostic feature of social phobia, also referred to as social anxiety
disorder by some, is the fear of social situations in which there exits the potential
or perceived potential for negative evaluation by others. As a result, the situations

are either avoided or endured with great distress (ICD-10 requires that avoidance
predominate). Behavioural expressions of the distress can include panic attacks,
more limited autonomic symptoms, or children may exhibit tantrums.
The ICD-10 includes two diagnostic categories for social phobia, one specific to
childhood, with an onset before age 6 (See Tables 5.7 and 5.8). The DSM no longer
has a child specific equivalent of Social Phobia; instead the diagnostic criteria include
qualifying notes for the application of the diagnosis to children (see Table 5.7).
The DSM-IV also notes that, with the exception of children, the patient must be
able to recognize that their fear is excessive. DSM-IV criteria require that social
anxiety in children is not limited to situations involving adults. No such limitation
exists in the ICD-10 criteria. In fact, in the diagnosis specific to childhood, ICD-10
notes that the symptoms may be limited to situations involving only adults, other
children, or both.
DSM-IV includes a specifier to indicate situations in which the disorder is gen-
eralized. This applies in cases in which the individual is fearful of most social
situations. DSM-IV is also more specific in that it requires symptoms continue for
a minimum of 6 months before a diagnosis of social phobia is considered.
Another distinction between the DSM-IV and ICD-10 concerns the scope of the
social phobia diagnosis. DSM-IV recognizes that, in contrast to situations in which
the generalized specifier applies, socially phobic individuals may become fearful of
very specific situations. If the focus of the fear is the potential for negative evalu-
ation by others, the social phobia diagnosis applies in the DSM system. Common
examples include public speaking fears and test/examination anxiety. According to
the ICD-10 the latter is considered a specific and not a social phobia (see Specific
Phobias).
Epidemiology

Epidemiological studies suggest that the prevalence rate for Social Phobia is approxi-
mately 1 per cent. Estimates vary widely, however, and it may be that these figures
are underestimates given that many socially phobic youth become embarrassed if
someone discovers their anxiety and therefore may be reluctant to report symptoms.

Studies with adults suggest that social phobia is slightly more prevalent in women
than in men; little data are available for children and adolescents, however.
The degree to which social extraversion is valued varies from culture to culture
and therefore the impairment associated with social anxiety could also be expected
Table 5.7. Diagnostic criteria for social phobia
DSM-IV ICD-10
A. A marked and persistent fear of one or more social or All of the following criteria should be fulfilled for a
performance situations in which the person is exposed to definite diagnosis:
unfamiliar people or to possible scrutiny by others. The (a) the psychological, behavioural, or autonomic
individual fears that he or she will act in a way (or show symptoms must be primarily manifestations of
anxiety symptoms) that will be humiliating or anxiety and not secondary to other symptoms such
embarrassing. Note: In children, there must be evidence of as delusions or obsessional thoughts;
the capacity for age-appropriate social relationships with (b) the anxiety must be restricted to or predominate in
familiar people and the anxiety must occur in peer settings, particular social situations; and
not just in interactions with adults. (c) avoidance of the phobic situations must be a
B. Exposure to the feared social situation almost invariably prominent feature.
provokes anxiety, which may take the form of a Includes:
situationally bound or situationally predisposed panic ∗ anthropophobia
attack. Note: In children, the anxiety may be expressed by ∗ social neurosis
crying, tantrums, freezing, or shrinking from social
situations with unfamiliar people.
C. The person recognizes that the fear is excessive or
unreasonable. Note: In children, this feature may be absent.
D. The feared social or performance situations are avoided or
else are endured with intense anxiety or distress.
E. The avoidance, anxious anticipation, or distress in the
feared social or performance situation(s) interferes
significantly with the person’s normal routine, occupational
(academic) functioning, or social activities or relationships,
or there is marked distress about having the phobia.
F. In individuals under age 18 years, the duration is at least
6 months.
G. The fear or avoidance is not due to the direct physiological
effects of a substance (e.g. a drug of abuse, a medication) or
a general medical condition and is not better accounted for
by another mental disorder (e.g. panic disorder with or
without agoraphobia, separation anxiety disorder, body
dysmorphic disorder, a pervasive developmental disorder,
or schizoid personality disorder).
H. H. If a general medical condition or another mental
disorder is present, the fear in Criterion A is unrelated to it,
e.g. the fear is not of Stuttering, trembling in Parkinson’s
disease, or exhibiting abnormal eating behaviour in
anorexia nervosa or bulimia nervosa.
Specify if:
Generalized: if the fears include most social situations (also
consider the additional diagnosis of avoidant personality
disorder)
Table 5.8. ICD-10 criteria for social anxiety disorder of childhood
Note: This diagnostic category is used only for disorders that arise before the age of 6 years, that
are both unusual in degree and accompanied by problems in social functioning, and that are
not part of some more generalized emotional disturbance.
Children with this disorder show a persistent or recurrent fear and/or avoidance of strangers;
such fear may occur mainly with adults, mainly with peers, or with both. The fear is associated
with a normal degree of selective attachment to parents or to other familiar persons. The
avoidance or fear of social encounters is of a degree that is outside the normal limits for the
child’s age and is associated with clinically significant problems in social functioning.
Includes: Avoidant disorder of childhood or adolescence
to vary. Children’s social roles also vary across cultures to a large extent, and this
may be particularly true when it comes to the ways in which children are expected
to interact with adults as well as the rigidity of social norms and the importance
placed on proper compliance. Therefore, in some cultures children may be expected
to behave in ways that may at first appear to be consistent with a diagnosis of social
phobia and the degree of distress experienced by the child as well as the deviation
from cultural norms needs to be carefully assessed. In some cultures children with
social phobias may be fearful of offending others, particularly adults, or may fear
that they will bring dishonour or embarrassment to their family as a result of
inappropriate behaviour in public.

Some degree of social anxiety in youth is not unusual particularly during adoles-
cence; however, social phobia can lead to significant impairment across most areas
of child’s life and may impact the family. Social phobia may also be seen with GAD
and depression.
Clinical picture

Children with social phobia may be reluctant to report their symptoms and much
information may have to be gathered through parent and teacher reports. School-
age children with social phobia may be most anxious in performance situations
such as giving speeches or having to perform in an athletic event or musical recital;
however, these events may be relatively rare and, as such, may not engender the same
degree of impairment as the informal social interactions that children encounter
everyday.
Some children with social phobia may have accompanying social skills deficits
that need to be addressed. Others possess age-appropriate social skills but their
anxiety interferes with the ability to demonstrate these skills and some socially
anxious children will demonstrate good social skills but will either perceive that
they are not performing properly when in social situations or they may fear that,
although they do not have a history of social skills problems, they may be unable
to behave appropriately in any future social situation.

Social phobia may also be seen with co-morbid depression and GAD and it is not
unusual for these conditions to be present in family members.
Socially phobic individuals may experience panic attacks or symptoms of panic
attacks when in social situations; however, if the panic attacks are limited to situ-
ations in which there is the perceived possibility of negative evaluation and this is
the focus of the anxiety, social phobia is a more appropriate diagnosis than PD.
Similar considerations must be taken in differentiating social phobia from a specific
phobia.
The avoidance of social situations seen in social phobia may also be confused with
the apathy experienced by depressed youth. When avoidance of social situations
co-occurs with hopelessness and apathy rather than anxious apprehension, the
diagnosis of depression should be considered.
Assessment
In addition to the general measures listed in Table 5.2, the Social Phobia Anxiety
Inventory for Children and the Social Anxiety Scales for Children and Adolescents
have been developed specifically to assess for social anxiety. Behavioural avoidance/
approach tests, described under specific phobias, can also be useful in the assessment
of social phobia.
Specific (isolated) phobias

The primary feature of specific phobias is the intense and unrealistic fear of specific
objects or situations. Both ICD-10 and DSM-IV specify that the feared object is
avoided whenever possible, or the DSM-IV also suggests that intense distress when
contact with the phobic stimulus occurs is diagnostically equivalent (see Table 5.9
for diagnostic criteria). The ICD-10 also includes a diagnostic category specific to
childhood (see Table 5.10).
Table 5.9. Diagnostic criteria for specific phobia
DSM-IV ICD-10
A. Marked and persistent fear that is excessive or All of the following should be fulfilled for a definite
unreasonable, cued by the presence or anticipation of a diagnosis:
specific object or situation (e.g. flying, heights, animals, (a) the psychological or autonomic symptoms must be
receiving an injection, seeing blood). primary manifestations of anxiety, and not secondary
B. Exposure to the phobic stimulus almost invariably to other symptoms such as delusion or obsessional
provokes an immediate anxiety response, which may take thought;
the form of a situationally bound or situationally (b) the anxiety must be restricted to the presence of the
predisposed panic attack. Note: In children, the anxiety particular phobic object or situation; and
may be expressed by crying, tantrums, freezing, or clinging. (c) the phobic situation is avoided whenever possible.
C. The person recognizes that the fear is excessive or Includes:
unreasonable. Note: In children, this feature may be absent. ∗ acrophobia
D. The phobic situation(s) is avoided or else is endured with ∗ animal phobias

intense anxiety or distress. ∗ claustrophobia
E. The avoidance, anxious anticipation, or distress in the ∗ examination phobia

feared situation(s) interferes significantly with the person’s ∗ simple phobia
normal routine, occupational (or academic) functioning,
or social activities or relationships, or there is marked
distress about having the phobia.
F. In individuals under age 18 years, the duration is at least
6 months.
G. The anxiety, panic attacks, or phobic avoidance associated
with the specific object or situation are not better
accounted for by another mental disorder, such as
obsessive-compulsive disorder (e.g. fear of dirt in someone
with an obsession about contamination), post-traumatic
stress disorder (e.g. avoidance of stimuli associated with a
severe stressor), separation anxiety disorder (e.g. avoidance
of school), social phobia (e.g., avoidance of social situations
because of fear of embarrassment), panic disorder with
agoraphobia, or agoraphobia without history of panic
disorder.
Specify type:
r Animal type
r Natural Environment type (e.g., heights, storms, water)
r Blood-injection-injury type
r Situational type (e.g. airplanes, elevators, enclosed places)
r Other type (e.g. phobic avoidance of situations that may
lead to choking, vomiting, or contracting an illness; in
children, avoidance of loud sounds or costumed characters)
Table 5.10. ICD-10 criteria for phobic anxiety disorder of childhood
This category should be used only for developmental phase-specific fears when they meet the
additional criteria that apply to all disorders in F93 [emotional disorders with onset specific to
childhood], namely that:
(a) the onset is during the developmentally appropriate age period;
(b) the degree of anxiety is clinically abnormal; and
(c) the anxiety does not form part of a more generalized disorder.
Excludes: Generalized anxiety disorder
Aside from the more specific criteria included in DSM-IV and the requirement
that the symptoms cause significant impairment in functioning; the two systems
also differ in that DSM-IV specifies five specific types of specific phobias: animal
type (e.g. fear of dogs, snakes, spiders), natural environment type (e.g. fear of
thunderstorms, heights, fires), situational type (e.g. fear of flying, fear of elevators),
blood-injection-injury type (e.g. fear of seeing blood, receiving an injection) and
other type (e.g. fear of choking) whereas ICD does not. ICD-10 also specifies that
the criteria for GAD cannot be met to receive the specific phobia diagnosis whereas
DSM-IV does not make this stipulation; moreover, ICD fails to specify a duration
criterion whereas DSM-IV indicates duration of at least 6 months. The implications
of these diagnostic differences for prevalence and incidence as well as assessment
and treatment currently are not known.
Epidemiology

Community surveys suggest that approximately 2.5 per cent of children and adol-
escents have specific phobias that engender significant impairment (using DSM
criteria). Rates across studies vary, however, and seem to be somewhat higher when
children provide information than when parent report is used as the basis for
diagnosis.

Little epidemiological data exist comparing the rate of specific phobias in boys and
girls; however, it appears that girls are slightly more likely to develop a specific
phobia than boys. However, the degree to which this is accurate varies widely
across the different types of phobias, with BII occurring more frequently in boys
than girls. Also self-reported fears tend to occur equally frequently in some cultures
(e.g. Africa) but more frequently in girls than boys in others (e.g. USA, United
Kingdom, Australia and China). Reasons for these differences are thought to be
determined culturally but the exact mechanisms are understood poorly at this
time.

Although specific fears are common throughout childhood and adolescence, it is
less common for these to reach the intensity and to cause the level of impairment
at which families seek treatment. However, treatment may be sought when the
child is unable to take part in a specific event or if the phobia interferes with social
activities. Often, specific phobias seen in clinical practice may be accompanied by
other anxiety problems.
Clinical picture

Youth presenting with Specific Phobias may be embarrassed about their fears but
may seek treatment when an upcoming event increases motivation for treatment.
Alternatively children with specific phobias may be seen when there are multiple
fears or phobias that together are causing considerable limitations. This may also
be the case when specific phobias are seen as part of a larger clinical picture that
may include other anxiety disorders or depression.

Panic attacks may occur as part of the symptom picture in a specific phobia; however,
with a phobia the panic attacks are situationally bound and fear remains focused
on the phobic stimulus and not the panic attacks. Specific phobias also need to
be differentiated from social phobia. If an object or event is feared because of the
possibility that it may be associated with public embarrassment or the negative
evaluation by others rather than the properties of the object or event itself, the
diagnosis of social phobia is more appropriate.
In some cases specific phobias can be confused with OCD. A phobic individ-
ual will attempt to avoid the feared stimulus or become distressed upon contact
but will not usually engage in compulsions that are not realistically connected to
avoiding harm from the feared stimulus. In addition, unless the phobic individual
is anticipating having to come into contact with the feared object there is not the
intrusive obsessive quality to the fear as seen in OCD.
As noted previously, specific phobias may be seen with other anxiety disorders.
Assessment
In addition to the interviews and questionnaires listed in Table 5.2, especially the
FSSC-R, behavioural avoidance/approach tests (BATs) can be useful in evaluat-
ing specific phobias and in monitoring treatment response. In a BAT the phobic
individual is confronted with the feared object and asked to approach as close as
he or she is able. In this way the individual’s comfort in approaching the feared
stimulus can be monitored easily by measuring the distance between the individual
and the object at the conclusion of each trial.
Self-monitoring can also be helpful in assessing the degree of interference caused
by avoidance of the feared object. Data collected can be simply frequency counts of
the number of times the feared stimulus is approached or avoided.
Aetiology
There is a growing body of evidence that suggests that the development and main-
tenance of the anxiety disorders in children occur as a function of synergistic pro-
cesses involving genetic, biological, familial, learning, and environmental forces.
Data supporting this position come from multiple sources including familial con-
cordance studies, twin studies, longitudinal studies of anxiety and temperament,
and experimental laboratory and behavioural studies. A number of familial studies,
for example, clearly reveal high concordance rates of anxiety among first-degree
relatives of anxiety-disordered patients. In addition, children of anxiety-disordered
parents and parents of anxiety-disordered children have been found to have far
higher rates of anxiety disorders than controls. Finally, the concordance rates of
anxiety symptoms and disorders have been shown to be higher in MZ than DZ
twins. Although these studies support a familial transmission of anxiety, the dif-
ferences in concordance rates between MZ twins relative to DZ twins are relatively
low compared to other disorders, suggesting the importance of shared genetic and
environmental factors. Thus, the genetic predisposition to the development of an
anxiety disorder can be said to be only a general one.
The exact nature of this genetic predisposition is not understood fully. However,
some data suggest that behavioural inhibition to the unfamiliar – a characteristic
of temperament – may be genetically based and may serve as a risk factor for the
development of an anxiety disorder. Behavioural inhibition is characterized by the
tendency to respond to novel situations with hesitancy, fear, reticence, and restraint.
Generally, children who are inhibited behaviourally are shy and fearful as toddlers,
quiet and withdrawn in unfamiliar situations in childhood, and introverted and
anxious as teenagers. Behavioural inhibition has been shown to be a relatively
stable characteristic that is associated with signs of sympathetic arousal (including
elevated heart rates and higher norepinephrine values), even in very young children.
In one study, children (2 to 7 years of age) of parents with PD were found to be
more likely to demonstrate this characteristic than children of parents with MDD or
other psychiatric disorders. In another study, children identified as behaviourally
inhibited were found to have higher rates of anxiety disorders than uninhibited
children. It is thus possible that this temperamental characteristic is a marker for a
predisposition that is genetically based and that serves to increase the vulnerability
for an anxiety disorder.
Although it is clear that anxiety disorders are familial, and it is possible that a
general predisposition for anxiety (rather than say a predisposition for a specific
anxiety disorder) is based genetically, the expression of any one anxiety disorder is
undoubtedly related to a transaction between life circumstances and developmen-
tal processes that occur throughout development and across the lifespan. Children
universally experience transient fears and anxieties over the course of development
that both are normal and evolutionarily adaptive. However, as this normal devel-
opmental process unfolds, certain perturbations occur and pathological fears and
anxieties may emerge. Developmental periods of increased vulnerability (e.g. sep-
aration from parents, entry into school, onset of puberty), in concert with certain
life events, may lead to the expression of any one specific anxiety disorder (say SAD
vs. PD versus GAD).
These life events and experiences affect, and undoubtedly are affected by, learning
experiences that shape particular anxiety responses and the subsequent develop-
ment of specific disorders. Through the processes of classical, operant and vicarious
conditioning, children learn that certain stimuli are associated with aversive con-
sequences, and that fearful and avoidant behaviours result in certain consequences
that may, at times, be reinforcing. Children of anxious parents may also be more
likely to observe overly anxious behaviour in their parents, and be more likely to
have fearful behaviour reinforced (inadvertently perhaps) by their parents (who
themselves may be averse to unpleasant and embarrassing situations than less anxi-
ous parents). Just as the child’s anxious behaviours are shaped inadvertently by
their parents, the parents’ behaviour may be reinforced negatively by their anxious
child becoming less upset and calm under such circumstances.
Thus, in brief, the aetiology of anxiety disorders in childhood is likely to be
a function of genetic, biological, familial, learning and environmental processes.
Life circumstances and events, in combination with the individual’s genetic and
biological predisposition and developmental transitions, may then determine the
development, expression, and form of any one anxiety disorder.
Treatment
Psychosocial interventions
The status of evidence-based practice for anxious and phobic children supports pri-
marily the use of cognitive–behaviour therapy (CBT) interventions. Several major
factors distinguish CBT for children from other psychosocial interventions for
youth:
r The focus of treatment is on maladaptive learning histories and erroneous or
overly rigid thought patterns.
r Treatment is focused on the here and now rather than orientated toward uncov-
ering historical antecedents of maladaptive behaviour or thought patterns.
r Treatment goals are clearly determined and parents and youth seeking treat-
ment are asked to delineate the types of changes they wish to see as a result of
treatment.
r Progress is monitored throughout treatment using objective indicators of change,
such as monitoring forms and the rating devices such as those discussed above
and described in Table 5.2.
r CBT is a skills-building approach.
r Because the goal of treatment is to develop skills that can be used outside of
treatment sessions and eventually independent of the therapist, CBT is often
action-orientated, directive, and educational in nature. Also for this reason, CBT
typically includes a homework component in which the skills learned in treatment
are practised outside the therapy room.
r CBTs for children often incorporate skills components for parents, teachers, and
sometimes even siblings or peers. For example, parents might be trained in how
to reward courageous behaviour and how to ignore (i.e. extinguish) excessive
reports of anxiety in their children.
r CBT is designed to be relatively short term, rarely extending beyond 6 months of
active treatment.
r In addition to the active treatment phase, CBT for anxious children may
incorporate spaced-out ‘booster sessions’ that extend over a longer period of
time (i.e. another 4 to 6 months) to ensure maintenance and durability of
change.
Table 5.11 lists some of the most common CBT treatment strategies for anxiety
disorders in youth. (In addition, a relaxation script for use with children is included
in Appendix 5.3.) These strategies are often used first in sessions and then practised
in related homework assignments outside of session by both the child and his or her
parents. A workbook is often provided to assist with these homework assignments.
Additionally, weekly monitoring of gains is pursued.
In summary, CBT interventions have been shown to be highly effective with
anxiety disorders in children. It should be noted that these treatments have been
used primarily with anxious children between 7 and 14 years of age and, as with
other problem areas and disorders, additional research is required to determine
whether these treatments will be effective with adolescents and younger chil-
dren. Still, it is obvious that they show considerable promise and recent work
with PD adolescents and preschool youngsters with SAD suggests their utility.
Given their proven effectiveness, they constitute the first line of treatment for
anxious children.
Table 5.11. Components of CBT treatments for anxiety disordered children and adolescents
Child components Parent components
Behavioural Cognitive Behavioural Cognitive

r Exposure to anxiety r Cognitive restructuring r Reinforcement of child’s r Problem solving
producing stimuli in anxiety provoking non-anxious behaviour
situations
r Self-reinforcement for r Coping self-talk r Planned ignoring for r Cognitive restructuring
non-anxious behaviour anxious behaviour around own anxiety
related to child’s fears
r Relaxation training r Recognizing and r Model problem solving
reinterpreting somatic non-anxious behaviour
sensations for child
r Role plays to practise r Cognitive restructuring
skills in anxiety of self-evaluations
provoking situations
Pharmacological interventions
There are few adequately designed studies available that establish the safety and
efficacy of any class of medication for the childhood anxiety disorders, with the
exception of OCD. Still, medication treatments have been used frequently and the
major options include the benzodiazepines, the tricyclic antidepressants (TCAs),
and serotonin re-uptake inhibitors (SSRIs). All have demonstrated efficacy in
adult anxiety disorders such as PD, GAD, and social phobia, although their effi-
cacy with children has not been well established. Moreover, these agents are not
as typically effective as CBT and appear to have reduced long-term favourable
outcomes.
As recommended by many clinicians and researchers, a detailed medical and
family history should be obtained, as well as laboratory measures, before beginning
any pharmacological regimen. For example, if a patient complains of feeling heat
intolerance with warm, moist skin, weight loss, and rapid heart rate, it would be
desirable to complete baseline thyroid studies. The prescribing clinician, with the
consent of parent and child, should consult with the child’s primary care physician
to be aware of any additional medical issues, and to determine if the child has
had a recent physical examination. Both the parent and child need to be informed
about the risks and benefits of medication treatment. It is also important to be clear
with the child and parent what target symptoms will be monitored to determine
effectiveness of the medication.
Benzodiazepines
The benzodiazepines bind to the γ -aminobutyric acid receptor (GABA) membrane
chloride channel complexes, which lead to enhanced CNS inhibition through the
neurotransmitter GABA. Besides the anxiolytic effect, benzodiazepines are also
used for their anticonvulsant, hypnotic and muscle relaxant properties. Although
an extensive literature exists regarding the effectiveness of benzodiazepines in adult
anxiety disorders, there have been only a few studies, with small sample sizes, that
have examined them in the childhood anxiety disorders. Most of the studies involve
children and adolescents who are co-morbid with other disorders such as major
depression and school refusal. The results of these studies, though limited, suggest:
r Benzodiazepines can be effective.
r However, it is unclear whether the benefits from the benzodiazepines can be fully
accounted for by placebo effects.
r Moreover, the side effects can be significant and considerable.
The most common side effects from benzodiazepines include:
r drowsiness
r headache
r nausea
r fatigue.
The side effects are dose related and can lead to tremor, slurred speech and ataxia.
There have also been reports of ‘paradoxical reactions’ where the child experi-
ences overexcitement, irritability and perceptual disorganization. Another concern
is the potential risk of dependence and withdrawal associated with the benzodi-
azepines – such concerns rule them out as a front-line treatment for the anxiety
disorders.
If children and adolescents are treated with benzodiazepines, it is recommended
that it be for a limited amount of time and at the lowest possible dose. As clinically
indicated, the dose should be increased every three to four days. Once treatment
is complete, the benzodiazepine should be tapered gradually to avoid any risk of
withdrawal symptoms, including insomnia, gastrointestinal complaints, rebound
anxiety and concentration difficulties.
Tricyclic antidepressants
Dysregulation of both the noradrenergic and serotonin system of the central ner-
vous system is thought to be related to the development of anxiety disorders. In
general, the effectiveness of the tricyclic antidepressants appears to be through the
metabolism and/or the re-uptake of the monoamine neurotransmitters. The sig-
nificant and often hard to tolerate side effects are due to the TCAs blockade at
the muscarinic/cholinergic, histamine (H1) and α-adrenergic receptors. The most
common side effects are constipation, nausea, orthostatic hypotension, sedation
and weight gain. The majority of clinical trials performed using TCAs did not have
children and adolescents with anxiety disorders alone, but rather the much more
complicated co-morbid group of ‘school refusing’ children. The placebo-controlled
studies of tricyclic antidepressants for anxiety-based school refusal children have
provided conflicting results.
An issue of grave concern with tricyclic antidepressant use in children is associated
with a growing recognition of cardiac risk. There have been reports of children who
died suddenly while being treated with appropriate dosages of desipramine. Given
the uncertain clinical efficacy of TCAs for anxiety-disordered children plus the
significant side effects, particularly the cardiac risk, this class of medication is also
not the first choice of action.
However, if these medications are used, the treating clinician should obtain
baseline vital signs including sitting and standing blood pressure with pulse, as
well as a baseline EKG. Once the therapeutic dose is reached, the EKG should be
repeated and serum levels should be checked. This should be repeated with each
significant dose adjustment.
Serotonin re-uptake inhibitors

The current state of the data regarding psychopharmacology leaves the SSRI antide-
pressants as the leading pharmacological candidate for the treatment of child-
hood anxiety disorders. The safety of the SSRIs recommends them as a choice,
as does their effectiveness in treating depression, which is frequently co-morbid
with childhood anxiety disorders. Moreover, the SSRIs have shown preliminary
efficacy in the treatment of adult anxiety disorders including GAD, PD and social
phobia.
There is limited but good evidence available for the use of SSRIs to treat childhood
anxiety disorders. Again, the majority of the studies include a mix of patients with
GAD, SAD, social phobia, PD, selective mutism and anxiety disorder not otherwise
specified.
r Open trials and one randomized trial suggest that fluoxetine has preliminary
benefit in the treatment of youth with OAD/GAD, SAD and social phobia.
r Sertraline has been shown to more effective in treating GAD in youth than a
placebo.
r The main side effects found with sertraline treatment were dry mouth, drowsiness,
leg spasms and restlessness. All of these side effects were more likely in children
treated with sertraline than with a drug placebo.
r Fluvoxamine has also been shown to be more effective than a placebo in treating
GAD, SAD and social phobia with or without co-morbid externalizing disorders.
r The main side effects found with fluvoxamine were increased motor activity or
agitation, which appears to be dose related, and abdominal discomfort.
In prescribing SSRIs, it is recommended that the medication be initiated at a low

dose, for example, with sertraline, 25 mg for the first 7 days, and then increased to
50 mg, increasing slowly as clinical response dictates. Once a therapeutic dose is
reached, this dose should be maintained for 6–8 weeks to determine its efficacy.
Withdrawal symptoms have been reported with the discontinuation of SSRIs,
including nausea, headache, dizziness and agitation. Therefore, these medications
should not be abruptly discontinued. From the available evidence on the effects
of medications, it appears that the SSRIs are a first-line psychopharmacological
treatment for childhood anxiety disorders.
Combining treatments in a multidisciplinary framework
Disease management model

It was clear by the late 1970s that a disease management model based on a psy-
chosocial approach was as powerful a change strategy in psychiatry as it was in
other areas of medicine. Consistent with this approach, combined treatment is the
rule rather than the exception across most of medicine, cf. the treatment of hyper-
tension with antihypertensives and weight reduction or the treatment of juvenile
rheumatoid arthritis with ibuprofen and physical therapy. In this regard, the treat-
ment of the anxious child can be thought of as partially analogous to the treatment
of juvenile-onset diabetes, with the caveat that the target organ, the brain in the
case of the anxiety disorders, requires psychosocial interventions of much greater
complexity. The treatment of diabetes and anxiety disorder both involve medica-
tions, insulin in diabetes and in anxiety, typically, a serotonin re-uptake inhibitor.
Each also involves an evidence-based psychosocial intervention that works in part
by biasing the somatic substrate of the disorder toward more normal functioning.
In diabetes, the psychosocial treatment of choice is diet and exercise, and in anxi-
ety, cognitive change and exposure-based CBT. However, not everybody recovers
completely even with the best of available treatments, so some interventions need
to target coping with residual symptoms, such as diabetic foot care in diabetes and
helping patients and their families cope skilfully with residual symptoms in the
anxiety disorders.
Combined psychosocial and pharmacological treatments

Psychosocial treatments usually are combined with medication for one of three
reasons.
r In the initial treatment of the child – especially the severely ill child – two treat-
ments may provide a greater ‘dose’ and thus may promise a better and perhaps
speedier outcome. For this reason, many patients with SAD, GAD, or PD opt for
combined treatment even though CBT alone may offer equal benefit.
r Co-morbidity frequently but not always requires two treatments, since different
targets may require different treatments. For example, treating an 8-year old who
has ADHD and SAD with a psychostimulant and CBT is a reasonable treatment
strategy. Even within a single anxiety disorder, important functional outcomes
may vary in response to treatment. For example, acute anticipatory anxiety in the
SAD child may be especially responsive to a benzodiazepine and reintroduction
to school with graduated exposure.
r In the face of partial response, an augmenting treatment can be added to the
initial treatment to improve outcome. For example, CBT can be added to an SSRI
for PD to improve PD-specific outcomes. In an adjunctive treatment strategy,
a second treatment can be added to a first one in order to impact one or more
additional outcome domains positively. For example, an SSRI can be added to
CBT for GAD to handle co-morbid depression or panic disorder.
A stages-of-treatment model
As a general rule, it is best to use the simplest, least risky and most cost-effective
treatment intervention available and to do so within a stages-of-treatment model
in order to identify key decision points in the everyday treatment of patients with
anxiety disorders. In particular, to be useful to clinicians, a treatment review should
address the following.
Selection of initial treatment

Given evidence-based psychotherapy and pharmacotherapy, and very few studies
of combined vs. unimodal treatment, the clinician must make a judgement about
the relative benefits and risks of single vs. combined treatment over the short and
long term. Besides relative effectiveness, the feasibility, acceptability and tolerability
of the treatment must also be considered. With these caveats in mind, some rough
guidelines for treatment selection are suggested in Fig. 5.1. In addition, to those
conditions depicted in Fig. 5.1, which suggest CBT as a first line of treatment,
clinicians may also want to turn to medication treatment if a sufficient trial of CBT
has not been successful. However, given that most readily available psychotherapies
do not typically use CBT procedures (particularly exposure), it would need to be
determined whether an adequate trial had taken place. Additionally, clinicians may
want to try medication as a first line treatment when developmental disorders or
cognitive limitations on the part of the child suggest that he or she may not be able
to fully engage in CBT treatment.
The management of partial response

Most patients improve substantially with current unimodal treatments. However,
it is likely that most will not normalize, especially when functional outcomes rather
Is there significant comorbidity?

no yes
Is there sufficient What is the

motivation for treatment? nature of the comorbid
disorder or
symptoms?
yes no
CBT SSRI Another anxiety Depression ADHD

or and disorder
CBT + family treatment CBT or CBT + family treatment
CBT + family treatment

CBT How severe
and
or is the
medication to
CBT + family treatment depression?
treat the ADHD symptoms*
mild/moderate severe
CBT
CBT
and
or
medication to
CBT + family treatment
treat the depression
*Note: There have been some reports of childrewn with comorbid ADHD and anxiety disorders developing tics with psychostimulant medication. These
tics may or may not remit with discontinuation of the medication treatment.
Fig. 5.1. Decision tree for determining first line of treatment for youth with anxiety disorders.
than symptoms are considered. Furthermore, when a primary disorder remits,

secondary problems often come to the fore. Thus, combining treatments is often
more common as treatment progresses and the limits of initial treatment become
apparent.
The treatment refractory patient

When a patient has had two trials of different medications, and, where appropriate,
combinations of medications as well as optimal psychosocial treatment, and where
these trials are adequate in dose and duration and the patient still shows little or
no improvement, it is justifiable to label the patient as treatment resistant. In this
situation, newer treatments, treatments with a lower probability of success and
riskier combinations of treatment all seem warranted.
Maintenance treatment
Finally, when a patient is a responder, it is critical from a personal and public
health perspective to know how long to continue treatment at what dose and visit
schedule before trying, if appropriate, to discontinue treatment. If discontinuation
is desirable, and it may not be in the face of persisting symptoms or previous
relapses, then the optimal schedule for discontinuing medications vs. psychosocial
treatment, given that these two modalities may show differences in durability of
benefit, must be considered.
Most of the time, the extant treatment literature and, typically, unsystematic
reviews of the treatment literature, do not provide much guidance once past the
choice of initial unimodal interventions. This is especially true for treatment reviews
that focus on either medication or psychosocial interventions alone and hence
cannot address issues associated with combining treatments. Because this leaves
out a significant number of patients for whom combined treatment is appropriate
if not de rigueur (e.g. partial responders to initial treatment, those who have failed
to respond to several treatments, and/or those who require a combination of treat-
ments because of co-morbidity), typical unsystematic treatment reviews are of less
use in clinical practice.
On being multidisciplinary
Although cognitive–behavioural and pharmacological treatment strategies for anx-
ious children combine readily, clinical psychology and psychiatry are often at odds
over stakeholder issues. We believe that it is not possible to practise competent and
ethical psychopharmacology without the availability of evidence-based psychoso-
cial interventions. Similarly, it is not possible to practise competent and ethical
psychotherapy without the availability of empirically supported psychopharma-
cology. Physicians (who typically write prescriptions) and psychologists (who, for
the most part, have developed and typically implement CBT) must join hands in the
care of individual patients if for no other reason than that the complexity of modern
mental health care is beyond the capacity of any one individual to master. Without
this commitment to multidisciplinary practice, we short change our patients.
Outcome
A growing body of literature documents the outcomes for both treated and
untreated youth with anxiety disorders. A review of the empirical literature suggests
the conclusions outlined below.
r Without treatment these disorders are persistent and they result in academic,
social and emotional complications for the youths who evince them.
r Recent advances suggest that CBT and the SSRIs are the most promising treatment
options
r With CBT, approximately two-thirds to three-quarters of children will experience
a remission of the anxiety disorder. Most will experience some reduction in
symptoms.
r The effects of CBT appear to continue after the active treatment phase is termin-
ated and most children whose symptoms remit after treatment will continue to be
diagnosis free for at least 1 year post-treatment. Additionally, a sizeable portion
of those children who experienced symptom relief but not total remission at the
end of treatment will continue to make improvements post-treatment.
r Adding a parent or family component to CBT for anxious children can increase
the success of treatment. Some evidence suggests that approximately 85 per cent
of children receiving this type of treatment will be diagnosis free at the end of
treatment and that this number grows even after the active phase of treatment
has been discontinued.
r Although we have less information about the use of medications with anxious
children, it appears that about three-quarters of children treated with SSRIs will
also experience remission of the disorder. However, it is also true that children
with anxiety disorders seem to experience a sizeable placebo effect in response to
medication treatment.
r The long-term maintenance of medication treatment is unknown at this time. We
also know little about combined treatments in children at this time. Speculation
based on adult studies, however, suggests that caution should be exercised when
combining CBT and medication treatments, in that long-term outcome may be
compromised.
r Finally, it will be imperative that we examine and treat these disorders from a
multidisciplinary perspective if we are to make significant and lasting advances.
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Appendix 5.1. Self-rating questionnaire (The Fear Survey Schedule for

Children – Revised, FSSC-R)

C Thomas H. Ollendick
B. Name: Age: Date:
Directions: A number of statements which boys and girls use to describe the fears
they have are given below. Read each carefully and put an X in the box in front
of the words that best describe your fear. There are no right or wrong answers.
Remember, find the words which best describe how much fear you have.
1. Giving an oral report . . . . . . None Some A lot

2. Riding in the car or bus . . . . None Some A lot
3. Getting punished by mother None Some A lot
4. Lizards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot

5. Looking foolish . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
6. Ghosts or spooky things . . . . . . . . . . . . . . . . . . . None Some A lot
7. Sharp objects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
8. Having to go to the hospital . . . . . . . . . . . . . . . . None Some A lot
9. Death or dead people . . . . . . . . . . . . . . . . . . . . . None Some A lot
10. Getting lost in a strange place . . . . . . . . . . . . . . None Some A lot
11. Snakes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
12. Talking on the telephone . . . . . . . . . . . . . . . . . . None Some A lot
13. Roller coaster or carnival rides . . . . . . . . . . . . . None Some A lot
14. Getting sick at school . . . . . . . . . . . . . . . . . . . . . None Some A lot
15. Being sent to the principal . . . . . . . . . . . . . . . . . None Some A lot
16. Riding on the train . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
17. Being left at home with a sitter . . . . . . . . . . . . . None Some A lot
18. Bears or wolves . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
19. Meeting someone for the first time . . . . . . . . . None Some A lot
20. Bombing attacks – being invaded . . . . . . . . . . . None Some A lot
21. Getting a shot from the nurse or doctor . . . . . None Some A lot
22. Going to the dentist . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
23. High places like mountains . . . . . . . . . . . . . . . . None Some A lot
24. Being teased . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
25. Spiders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
26. A burglar breaking into our house . . . . . . . . . . None Some A lot
27. Flying in an airplane . . . . . . . . . . . . . . . . . . . . . . None Some A lot
28. Being called on by the teacher . . . . . . . . . . . . . . None Some A lot
29. Getting poor grades . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
30. Bats or birds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot

31. My parents criticizing me . . . . . . . . . . . . . . . . . . None Some A lot
32. Guns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
33. Being in a fight . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
34. Fire – getting burned . . . . . . . . . . . . . . . . . . . . . . None Some A lot
35. Getting a cut or injury . . . . . . . . . . . . . . . . . . . . None Some A lot
36. Being in a big crowd . . . . . . . . . . . . . . . . . . . . . . None Some A lot
37. Thunderstorms . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
38. Having to eat some food I don’t like . . . . . . . . None Some A lot
39. Cats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
40. Failing a test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
41. Being hit by a car or truck . . . . . . . . . . . . . . . . . None Some A lot
42. Having to go to school . . . . . . . . . . . . . . . . . . . . None Some A lot
43. Playing rough games during recess . . . . . . . . . None Some A lot
44. Having my parents argue . . . . . . . . . . . . . . . . . . None Some A lot
45. Dark rooms or closets . . . . . . . . . . . . . . . . . . . . . None Some A lot
46. Having to put on a recital . . . . . . . . . . . . . . . . . . None Some A lot
47. Ants or beetles . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
48. Being criticized by others . . . . . . . . . . . . . . . . . . None Some A lot
49. Strange looking people . . . . . . . . . . . . . . . . . . . . None Some A lot
50. The sight of blood . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
51. Going to the doctor . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
52. Strange or mean looking dogs . . . . . . . . . . . . . . None Some A lot
53. Cemeteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
54. Getting a report card . . . . . . . . . . . . . . . . . . . . . . None Some A lot
55. Getting a haircut . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
56. Deep water or the ocean . . . . . . . . . . . . . . . . . . . None Some A lot

57. Nightmares . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
58. Falling from high places . . . . . . . . . . . . . . . . . . . None Some A lot
59. Getting a shock from electricity . . . . . . . . . . . . None Some A lot
60. Going to bed in the dark . . . . . . . . . . . . . . . . . . None Some A lot
61. Getting car sick . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
62. Being alone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
63. Having to wear clothes different from others. None Some A lot
64. Getting punished by my father . . . . . . . . . . . . . None Some A lot
65. Having to stay after school . . . . . . . . . . . . . . . . . None Some A lot
66. Making mistakes . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
67. Mystery movies . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
68. Loud sirens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
69. Doing something new . . . . . . . . . . . . . . . . . . . . . None Some A lot
70. Germs or getting a serious illness . . . . . . . . . . . None Some A lot
71. Closed spaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
72. Earthquakes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
73. Terrorists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
74. Elevators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
75. Dark places . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
76. Not being able to breathe . . . . . . . . . . . . . . . . . . None Some A lot
77. Getting a bee sting . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
78. Worms or snails . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
79. Rats or mice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
80. Taking a test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None Some A lot
Appendix 5.2. The Childhood Anxiety Sensitivity Index

(Silverman, Fleisig, Rabian & Peterson, 1991)
Directions: A number of statements which boys and girls use to describe themselves
are given below. Read each statement carefully and put an ‘X’ in the blank in front
of the words that describe you. There are no right or wrong answers. Remember,
find the words that best describe you.
1. I don’t want other people to know when I feel

afraid. None Some A lot
2. When I cannot keep my mind on my schoolwork

I worry that I might be going crazy. None Some A lot
3. It scares me when I feel ‘shaky’. None Some A lot
4. It scares me when I feel like I am going to faint. None Some A lot
5. It is important for me to stay in control of my

feelings. None Some A lot
6. It scares me when my heart beats fast. None Some A lot
7. It embarrasses me when my stomach growls

(makes noise). None Some A lot
8. It scares me when I feel like I am going to

throw up. None Some A lot
9. When I notice that my heart is beating fast,

I worry that there might be something wrong
with me. None Some A lot
10. It scares me when I have trouble getting my

breath. None Some A lot
11. When my stomach hurts, I worry that I might be

really sick None Some A lot
12. It scares me when I can’t keep my mind on my

schoolwork. None Some A lot
13. Other kids can tell when I feel shaky. None Some A lot
14. Unusual feelings in my body scare me. None Some A lot

15. When I am afraid, I worry that I might be crazy. None Some A lot
16. It scares me when I feel nervous. None Some A lot
17. I don’t like to let my feelings show. None Some A lot
18. Funny feelings in my body scare me. None Some A lot
Appendix 5.3. A relaxation training script for children (Ollendick, 1978)
Hands and arms

Make a fist with your left hand. Squeeze it hard. Feel the tightness in your hand and
arm as you squeeze. Now let your hand go and relax. See how much better your
hand and arm feel when they are relaxed. Once again, make a fist with your left
hand and squeeze hard. Good. Now relax and let your hand go. (Repeat the process
for the right hand and arm.)
Arms and shoulders

Stretch your arms out in front of you. Raise them high up over your head. Way
back. Feel the pull in your shoulders. Stretch higher. Now just let your arms drop
back to your side. Okay, let’s stretch again. Stretch your arms out in front of you.
Raise them over your head. Pull them back, way back. Pull hard. Now let them drop
quickly. Good. Notice how your shoulders feel more relaxed. This time let’s have
a great big stretch. Try to touch the ceiling. Stretch your arms way out in front of
you. Raise them way up high over your head. Push them way, way back. Notice the
tension and pull in your arms and shoulders. Hold tight now. Great. Let them drop
very quickly and feel how good it is to be relaxed. It feels good and warm and lazy.
Shoulders and neck

Try to pull your shoulders up to your ears and push your head down into your
shoulders. Hold in tight. Okay, now relax and feel the warmth. Again, pull your
shoulders up to your ears and push your head down into your shoulders. Do it
tightly. Okay, you can relax now. Bring your head out and let your shoulders relax.
Notice how much better it feels to be relaxed than to be all tight. One more time
now. Push your head down and your shoulders way up to your ears. Hold it. Feel the
tenseness in your neck and shoulders. Okay. You can relax now and feel comfortable.
You feel good.
Jaw
Put your teeth together real hard. Let your neck muscles help you. Now relax. Just
let your jaw hang loose. Notice how good it feels just to let your jaw drop. Okay,
bite down again hard. That’s good. Now relax again. Just let your jaw drop. It feels
so good just to let go. Okay, one more time. Bite down. Hard as you can. Harder.
Oh, you’re really working hard. Good. Now relax. Try to relax your whole body. Let
yourself go as loose as you can.
Face and nose

Wrinkle up your nose. Make as many wrinkles in your nose as you can. Scrunch
your nose up real hard. Good. Now you can relax your nose. Now wrinkle up your
nose again. Wrinkle it up hard. Hold it just as tight as you can. Okay. You can
relax your face. Notice that when you scrunch up your nose that your cheeks and
your mouth and your forehead all help you and they get tight, too. So when you
relax your nose, your whole face relaxes too, and that feels good. Now make lots of
wrinkles on your forehead. Hold it tight now. Okay, you can let go. Now you can
just relax. Let your face go smooth. No wrinkles anywhere. Your face feels nice and
smooth and relaxed.
Stomach
Now tighten up your stomach muscles real tight. Make your stomach real hard.
Don’t move. Hold it. You can relax now. Let your stomach go soft. Let it be as
relaxed as you can. That feels so much better. Okay, again. Tighten your stomach
real hard. Good. You can relax now. Kind of settle down, get comfortable, and relax.
Notice the difference between a tight stomach and a relaxed one. That’s how we
want it to feel. Nice and loose and relaxed. Okay. Once more. Tighten up. Tighten
hard. Good. Now you can relax completely. You can feel nice and relaxed.
This time, try to pull your stomach in. Try to squeeze it against your backbone.
Try to be as skinny as you can. Now relax. You don’t have to be skinny now. Just
relax and feel your stomach being warm and loose. Okay, squeeze in your stomach
again. Make it touch your backbone. Get it real small and tight. Get as skinny as
you can. Hold tight now. You can relax now. Settle back and let your stomach come
back out where it belongs. You can really feel good now. You’ve done fine.
Legs and feet

Push your toes down on the floor real hard. You’ll probably need your legs to help
you push. Push down, spread your toes apart. Now relax your feet. Let your toes go
loose and feel how nice that is. It feels good to be relaxed. Okay. Now push your toes
down. Let your leg muscles help you push your feet down. Push your feet. Hard.
Okay. Relax your feet, relax your legs, relax your toes. It feels so good to be relaxed.
No tenseness anywhere. You feel kind of warm and tingly.
Source: Ollendick, T. H. & Cerny, J. A. (1981). Clinical Behavior Therapy with
Children. New York: Plenum Press.
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Chapter · January 2005

Thomas Ollendick Laura Diane Seligman

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Cross-cultural assessment and treatment of social anxiety View project

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A Clinician’s Handbook of Child and Adolescent Psychiatry, ed. Christopher Gillberg,

Separation anxiety disorder (SAD)

Definition and classification

Table 5.1. Diagnostic criteria for separation anxiety disorder

Table 5.1. (cont.)

Prevalence and incidence rates

adolescence decreases to less than 1 per cent. However, in prepubertal children

Sex ratios and ethnicity

Implications for clinical practice

Main features and symptoms

Differential diagnosis and co-morbidity

Generalized anxiety disorder

Definition and classification

Instrument Description Subscales/procedural comments Psychometric properties

Instrument Description Subscales/procedural comments Psychometric properties

Instrument Description Subscales/procedural comments Psychometric properties

Table 5.3. Diagnostic criteria for generalized anxiety disorder

adolescents, 1 for children). DSM-IV also requires clinically significant impairment

Prevalence and incidence rates

Sex ratios and ethnicity

Implications for clinical practice

Main features and symptoms

Differential diagnosis and co-morbidity

Definition and classification

Table 5.4. Diagnostic criteria for panic disorder

interpret them as dangerous or become preoccupied with a possible reoccurrence

Table 5.5. DSM-IV definition of a panic attack

Table 5.6. DSM-IV definition of agoraphobia

although this latter diagnosis is less commonly applied, especially in children. No

crowded places or a fear of situations in which escape might be difficult. Although

Prevalence and incidence rates

Sex ratios and ethnicity

Implications for clinical practice

Main features and symptoms

Differential diagnosis and co-morbidity

Social phobia (social anxiety disorder)

Definition and classification

or perceived potential for negative evaluation by others. As a result, the situations

Prevalence and incidence rates

Sex ratios and ethnicity

Table 5.7. Diagnostic criteria for social phobia

Table 5.8. ICD-10 criteria for social anxiety disorder of childhood

Implications for clinical practice

Main features and symptoms

Differential diagnosis and co-morbidity

Specific (isolated) phobias

Definition and classification

Table 5.9. Diagnostic criteria for specific phobia

D. The phobic situation(s) is avoided or else is endured with ∗ animal phobias

E. The avoidance, anxious anticipation, or distress in the ∗ examination phobia

Table 5.10. ICD-10 criteria for phobic anxiety disorder of childhood

Prevalence and incidence rates

Sex ratios and ethnicity

Implications for clinical practice

Main features and symptoms

Differential diagnosis and co-morbidity

Child components Parent components